HEALTH SYSTEM

Government role

Regionally administered universal public insurance program that plans and funds (mainly private) provision

Public system financing

Provincial / federal general tax revenue

Private insurance role

~67% buy complementary coverage for non covered benefits (e.g., private rooms in hospitals, drugs, dental care, optometry)

Provider ownership

Primary care: Private

Hospitals: Mixed public and private

Provider payment

Primary care payment: Mostly fee-for-service (~45% to 85%, depending on province), but some alternatives (e.g., capitation) for group practices

Hospital payment: Mostly global budgets, case-based payment in some provinces (does not include physician costs)

Primary care role

Registration with GP required: Not generally, but yes for some capitation models

Gatekeeper: Yes, mainly through financial incentives varying across provinces (e.g., in most provinces, specialists receive lower fees for patients not referred)

HOW IS THE MEDICAL SERVICE ORGANIZED

Primary care

Primary care physicians act as gatekeeper. Many provinces pay lower fees to specialists for non-referred consultations. Most physicians are self employed. Patients have freedom of choice of primary care doctor. The requirement for registration varies. The fees schedules are fixed. In some provinces payment incentives are linked to performance.

Outpatient specialist care

Most of specialists work in hospitals. They are mostly self employed. In most provinces they have the same fee-schedule as as primary care physicians. Patients can have direct access to specialist however it is common to for GPs to refer patients to specialist. Specialists working in the public are not allowed to get payment from private patients for publicly insured service.

Direct payments to providers

Most of the primary care physicians and specialist bill provincial governments directly, although some are paid a salary by the hospital or facility. There is no payment from patients directly to physicians. There is no cost-sharing however patients may be required to pay out of pocket for services that are not medically necessary.

After hours care

For after hours care patients can use hospital emergency rooms or physician led (mainly privately owned) walk-in clinics. Furthermore a free telehealth service exists which is a 24 hours a day health advice from a registered nurse. Traditionally primary care physicians were not required to provide after hours care. However there are government enabled group practices arrangements.

Hospitals

There is a mix of private and public hospitals often managed locally and often non-for-profit organization. They are mostly operating on an annual budget which is negotiated with the the authorities. Generally the physicians are not hospital employees and are paid fee-for-service directly.

Mental Health Care

Hospital mental health care is provided in specialist psychiatric hospitals or general hospitals with mental health beds. There is a universal coverage for physician-provided health care. Psychologist may work privately and are paid out-of-pocket or through private insurance. Mental health has not been formally integrated into primary care.

Long-term Care

Long-term care and end-of-life-care is offered in non hospital facilities. All provinces provide some nursing home care. Eligibility criteria for home and long-term care services generally include the needs assessment based on the health status and functional impairment.